The TUG (transverse upper gracilis) flap uses the gracilis muscle, located in the upper inner thigh. This muscle starts at your pubic bone and ends along the inside of your upper leg. The gracilis muscle helps you bring your leg toward your body. It’s important to know that with TUG flap surgery, you will no longer be able to use this muscle.
During TUG flap surgery, a flap of skin, fat, muscle, and blood vessels from your upper thigh is used to reconstruct the breast. The flap is moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the TUG flap to the blood vessels in your chest using microsurgery.
The TUG flap may be a good reconstruction choice for women who aren't good candidates for TRAM, DIEP, or SIEA flaps because there’s not enough donor tissue in the belly area, or they’ve had previous flaps that failed and are seeking a secondary alternative.
The TUG flap may be a good option for women with small-sized breasts. If you have larger breasts and your doctor recommends TUG flap reconstruction because of your unique situation, you'll probably need a saline or silicone implant to achieve your desired size.
Because skin, fat, and blood vessels are moved from your upper thigh to your chest, having a TUG flap means your thigh will be tighter — as if you had an inner thigh lift. If TUG flap surgery is used to reconstruct one breast, there can be some unevenness in the thighs. If you want to avoid this, talk to your surgeon about other options. (A newer type of DIEP surgery, called “stacked DIEP,” is often a good option for women who don’t have enough belly tissue for a standard DIEP. However, this surgery is not widely available.) If you’re having both breasts reconstructed, though, your surgeon would take a TUG flap from both thighs, which means both thighs would be thinner. TUG flap surgery is possible even if you’ve had previous liposuction on the thighs.
A TUG flap procedure leaves a scar on your upper inner thigh, but most surgeons will usually tuck into the crease at the top of your thigh. In some cases, the scar might be a little lower and may be visible when you're wearing a bathing suit. TUG flaps do tend to have more healing problems at the donor site than other flap surgeries due to the location of the incision.
TUG flap reconstruction: What to expect
During TUG flap surgery, an incision is made in your upper thigh near your groin, and an oval section of skin, fat, blood vessels, and muscle is taken from your thigh and moved up to your chest and formed into a breast shape. The tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope.
TUG flap reconstruction surgery takes about 3 to 4 hours.
After TUG flap reconstruction surgery: You'll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you're in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.
You'll then be admitted to a hospital room. For a TUG flap, you usually stay in the hospital for about 3 days.
Your doctor will give you specific instructions to follow for your recovery. For detailed information on how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect page.
It can take about 4 weeks to recover from TUG flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you've had surgery at two or possibly four sites on your body (your chest and your thigh or both thighs), you might feel worse than someone who had mastectomy alone and it will probably take you longer to recover. You'll have to take care of two or possibly four incisions: on your breast(s) and your thigh(s). You may have another incision and a surgical drain if you also had axillary dissection (underarm lymph node removal) at the same time.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You usually have to avoid strenuous sports, sexual activity, and lifting anything heavy for about 4 to 6 weeks after TUG flap reconstruction. Recovery may be a bit awkward because of where the incision is placed. You can walk, but you’ll need to avoid movements that flex the hips or spread the legs. Talk to your doctor about the healing process and how to tell if your incisions aren’t healing well.
TUG flap surgery risks
Like all surgery, TUG flap surgery has some risks. Many of the risks associated with TUG flap surgery are the same as the risks for mastectomy. If you've had an implant inserted along with TUG flap reconstruction, there are also risks unique to implant reconstruction. However, there are some risks that are specific to TUG flap reconstruction.
Tissue breakdown: In rare instances, the tissue moved from your thigh to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.
Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don't go away on their own, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having it removed can give you greater peace of mind, as well as ease any discomfort you might have.
— Last updated on February 9, 2022, 8:32 PM